GW1--02976_Well Construction - GW1_20240513

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dW#LlL¢..DNS Il'RUCT ON RECORD(GW-Il) For Internal Use Only:
I.Well Contractor Information:
Chris King •
14.WATER ZONES , ,
Well Contractor Name FROM TO DESCRIPTION
2080-A of on' cx,6 a ft. f � 1 f 1 r1
NC Well Contractor Certification Number ft. ft.
15.OUTER CASING(for multi-cased wells)OR LINER(if ap likable)
Aqua Drill, Inc. FROM • ..7 PTO- DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 0 0- I l�•r xf in. I Spe 2 fD pi v d C _
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: ?25-4 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consn action permits(Le.U/C.County.State.Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. In. _
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
1 Municipal/Public O in.
Geothermal(Heating/Cooling Supply) csidcntial Water Supply(single)
IndustriallConunercial O• R. in.
Residential Water Supply(shared)
Irrigation 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring
injection Well:
y� ii
ORecovcry ® ft. � O• AJ�d� i•�Ir �lip 11'
O. ft. ff
Aquifer Recharge i Groundwater Remediationalinity Barrier
ft. O'
Aquifer Storage and Recovery S 19.SAND/GRAVEL PACK(if applicable)
FROM MATERIAL
20.Aquifer Test QStormwater Drainage ft. ft,
Experimental Technology Subsidence Control O, O.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DFSCRIPT..ION(colo,hardness.solumch type.grain size.cta.)
0 R• /2 ft. 501I
4.Date Well(s)Completed:57.7-62 9 Well iD# tt. O.
J� �5� Sic)lud 1ZOc1C .
Sa.Well Location: Lis-
(t, S'[) '
131=0 c 6illlir!I1I4 e
-56N114.kciaJ soon,c ft. ft.
Facifity!Owas Name Facility iD#(if applicable) ft. ft. 17, -'
J p �iai.'C G'ya;//c.. pis�r ft. O. c < . ?I.
_. ,y�
Physical Address.City,and Zip O. ft.
C.06�e I I 21.REMARKS MAY 20?4
County
Parcel Identification No.(PIN) !f.f:C^ .:•�: t r. 7,1,:-✓ �r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: it.e t't ltv
(if well f+cld_one lattlong is sufficient)
22.Certi6 'on:
N W
_
6.Is(are)the woll(sAPermancnt or Temporary Signature of Certified Wcll Contracto
Date
7.Is this a repair to an existin wCU Br signing this Arm.I hereby certj•that the well(s)was(were)constructed in acconbace
g : DYes or 1•4 No with ISA NCAC 02C.0/00 or ISA NCAC 02C.0200)cell Construction Standards and that a
/f this is a repair,fi/l out known well cannrueBnn infiwniatfon and explain the nature r f the copy of this rayon(has been pnwided to the well owner.
repair under 021 remarks section or on the buck r fthis tam.
23.Site diagram or additional well details: _
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary,
drilled:
s---6 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For multiple welts list all depths(Miff. ut wimple-3tth2)0'and 3(iolOU) 24a. For MI Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level ben top of casing: (ft.)1+�nrcrlrrel is above casing t c -fDivision of Water Resources,Information Processing Unit,
1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (In.)
24b.For infection.Wells: in addition'to sending the form to the address in 24a
12.Well construction method: ) �Z D 1 above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct pub,etc. construction to the following: I
Division of Water Resources,Under
ground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
/ ) C 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ,Z Method of test: J t lj f 4- 24e.For Water Supply&infection Wells: In addition to sending the form to
13b.Disinfection type: the address(es) above, also submit one copy of this form within 30 days of
Amount: )6 6 Z.. completion of well construction to the county health department of the county
where constructed.
Form OW-! North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016